CNS Vital Signs Neurocognitive Case Studies Adding Value to Your Practice by Providing Solutions for Measuring,  Monitoring and Managing Neurocognitive and Behavioral Health…

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Introduction This Case Study Guide is designed to give clinicians helpful information about the use of CNS Vital Signs neurocognitive  testing, behavioral assessments, and mental health screening. It includes a variety relevant patient and practice examples  that may be used to address HOW CNS Vital Signs neurocognitive and behavioral health assessment platform can be used  across the lifespan e.g., children, adolescent, adult and senior patients to gain deeper clinical insight and to help manage  treatments. It also provides suggestions for combinations of codes that can be used when offering services and testing  procedures using the CNS Vital Signs assessment platform capabilities. Please note that this information is designed to  provide helpful tips regarding the actual use by CNS Vital Signs clinicians and has not been peer reviewed. It is also recommended that clinical users consult our peer‐reviewed papers including our Validity & Reliability paper  published in the “Archives of Clinical Neuropsychology’ listed at the PULLICATIONS section of the CNS Vital Signs website.   To learn more about the CNS Vital Signs neurocognitive testing, behavioral assessments, and mental health screening  platform and how it will work best for your practice or research project  you should schedule a FREE CNS Vital Signs  webinar.  EACH CNS Vital Signs Webinar can cover topics such as:     

Clinical Use including… Test Report Interpretation Billing & Coding Validity & Reliability Research Applications Practice Efficiencies and much more…

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

At the top of the CNS Vital Signs  Homepage CLICK

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Brief Clinical Procedure Case Study Examples AD/HD    

Adolescent Assessment and Medication Management College Student Assessment and Medication Management AD/HD Evaluation and Cogmed Evidence‐Based Outcomes Neurobehavioral Feedback Longitudinal Tracking

TBI & PTSD   

27 year old Marine… 2 IED’s in Iraq… TBI & PTSD Posit Science Brain Fitness (24 yo professional baseball player) Cognitive Resilience Training

SLEEP 

Sleep Disorder Patient

OTHER   

Cognitive Fatigue; Sorting Out Comorbidities; Folic Acid, Plus Stimulant Measure Aerobic Exercise  Use in MCI Dementia

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Free Neuropsych Questionnaire NPQ-207 In-Take Tool for Assessing Symptoms and Possible Comorbidities NeuroPsych Questionnaire (NPQ) LF-207 (Page 1 of 8)

= Key Symptoms

Age: 12 (Informant Survey by Mother)

Administrator: Med Tech

Total Test Time: 10:31 (min:secs)

Language: English (United States)

Domain Attention Impulsive Learning Memory Anxiety Panic Agoraphobia Obsessions & Compulsions Social Anxiety Depression Mood Stability Oppositional Mania Aggression Psychotic Somatic Fatigue Sleep Suicide Pain

Reported Symptoms

Johnny’s mother completed  this 207 questionnaire of  possible neuropsych symptoms  and possible comorbidities in  the waiting room using an I‐ pad and the results were auto‐ scored. Based on clinic policy  the results were printed and  reviewed. Noticing the  possibility of AD/HD from his  school record and the NPQ  Johnny was given the CNS Vital  Signs BRIEF‐CORE assessment  prior to the clinician  interviewing and examining  the patient.

Test Date: February 11 2009 11:24:43

Score 208 225 145 157 114 33 33

Severity Moderate Severe Mild Moderate Mild Not a Problem Not a Problem

56

Not a Problem

100 136 108 145 17 80 43 56 0 0 83 83

Mild Moderate Moderate Mild Not a Problem Mild Not a Problem Not a Problem Not a Problem Not a Problem Mild Mild

Average Symptom Score

142

Mild

PTSD Bipolar Autism Aspergers ADHD MCI Concussion Anxiety/Depression

85 100 46 81 197 173 111 110

Mild Mild Not a Problem Mild Moderate Moderate Mild Mild

Possible Comorbidities

Johnny, a twelve year old boy   struggling in school was  referred to a Neuropsychiatrist   by the school for additional   AD/HD evaluation and  management. 

Subject Reference/ID: AD/HD Case Study

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

Description The Neuropsych Questionnaire asks patients (or an appropriate observer) a series of questions about their clinical state. The questions are about the symptoms of various neuropsychiatric disorders. The terminology is similar to that used in the diagnostic manuals, and in many familiar clinical questionnaires and rating scales; but it has been simplified, and all symptoms are scored on the same metric. Scores are reported on a scale of 0 (not a problem) to 300 (severe). As a rule, scores above 225 indicate a severe problem; scores from 150-224 indicate a moderate problem; and scores from 75149, a mild problem. A high score on the Neuropsych Questionnaire means that the patient is reporting more symptoms of greater intensity. It doesn't necessarily mean that the patient has a particular condition; just that he or she (or their spouse, parent or caregiver) are saying that they have a lot of intense symptoms. Conversely, a low score simply means that the patient (or caregiver) is not reporting symptoms associated with a particular condition, at least during the period of time specified. It does not mean that the patient does not have the condition. Just as some people over-state their problems, others tend to under-state their problems. The Neuropsych Questionnaire is not a diagnostic instrument. The results it generates are only meant to be interpreted by an experienced clinician in the course of a clinical examination.

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Every patient with ATTENTION DEFICIT has a Unique PROFILE. Johnny, a twelve year old boy   struggling in school was given  CNS Vital Signs VSX BRIEF‐ CORE Clinical Battery… he  scored below average in 5 of 9  cognitive domains (pre‐dose).  After examining the H&P, the  test results, and the PCS ‐ pediatric symptom checklist &  Vanderbilt  AD/HD rating  scales; Johnny was given a  prescription medication. Four  weeks later he was  administered the test again  (post‐dose). The CNS Vital Signs  report is  available seconds after the  testing session ends and is a  useful tool for assessing  academic and vocational  accommodations as well as  measuring  medication effect  and helping clinicians  tailor  medications to get the  minimum dose vs. maximum  neurocognitive effect. 

Pre Dose

Post Dose

Domains most sensitive to attention deficit conditions.

“For the first time I am able to show my son that his mind functions better when he is on his medication than when he is not…” Johnny's Mother

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

“Our relatives are always giving us a hard time about giving our boys AD/HD medicine. For the first time I have proof that they need their medicine.” Johnny's Father

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College Student Attention Deficit Case Study 1 PRE: Part of AD/HD Assessment Protocol

= Low Frontal Lobe Domain Scores

Patient History: James K. a 21 year old college student on a Presidential scholarship for his piano playing ability. James is gifted musically, has played with  symphony orchestras, and can watch someone play a musical piece then repeat from memory the piece. James’ high school academic  performance was average and he was a popular student. At college James has struggled, he reports he has a problem concentrating in the  library compared to his peers. He has struggled with a number of courses and has dropped at least one course per semester. A peer in his  dorm told James he should  “get some Adderall”.  James was referred for  clinical evaluation.  Clinical Findings: As part of the patient in‐take he was administered the Adult ADHD Self‐Report Scale in which he scored a 40 overall and a 25 in the  ‘inattentive’ category (24 or greater = Highly likely to have ADHD). James was also administered the CNS Vital Signs neurocognitive  1 assessment  and was identified as having possible frontal lobe deficits. Based on this information James was given the Brown  ADD Scales  which confirmed possible executive and attentional dysfunction. Reviewing James’ initial Domain Dashboard confirms James has above  average skills in Memory, Processing Speed, and Psychomotor Speed which would be expected  given his considerable piano playing skills.  Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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College Student Attention Deficit Case Study 1 PRE: Part of AD/HD Assessment Protocol James K. 21 Year Old College Student: Adult ADHD Self-Report Scale (ASRS-v1.1) 1

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

3 ‐ Often

2

How often do you have difficulty getting things in order when you have to do a task that requires organization?

3 ‐ Often

3

How often do you have problems remembering appointments or obligations?

2 ‐ Sometimes

4

When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

4 ‐ Very Often

5

How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

1 ‐ Rarely

6

How often do you feel overly active and compelled to do things, like you were driven by a motor?

2 ‐ Sometimes

7

How often do you make careless mistakes when you have to work on a boring or difficult project?

4 ‐ Very Often

8

How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

4 ‐ Very Often

9

How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

2 ‐ Sometimes

Part A (Inattentive)

25

10

How often do you misplace or have difficulty finding things at home or work?

11

How often are you distracted by activity or noise around you?

3 ‐ Often

12

How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

1 ‐ Rarely

13

How often do you feel restless or fidgety?

0 ‐ Never

14

How often do you have difficulty unwinding and relaxing when you have time to yourself?

2 ‐ Sometimes

15

How often do you find yourself talking too much when you are in social situations?

2 ‐ Sometimes

16

When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to,  before they can finish them themselves?

2 ‐ Sometimes

17

How often do you have difficulty waiting your turn in situations when turn taking is required?

0 ‐ Never

18

How often do you interrupt others when they are busy?

1 ‐ Rarely

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

4 ‐ Very Often

Part B (Hyperactive/Impulsive)

15

ASRS Total Score

40

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College Student Attention Deficit Case Study 2 POST: Part of AD/HD Assessment Follow-up

The Results: James was prescribed 20mg of Vyvanse™ and returned for a follow‐up to measure the impact of Vyvanse™ on neurocognitive function. The  Domain Dashboard test scores,  2 POST‐MEDICATION, reveals a beneficial or positive shift in his neurocognitive function. No side‐effects  were experienced or observed by the student. The college health center provided James with copies of his tests which he was able to share  with his family. The family was impressed that the CNS Vital Signs test was able to quantify and illuminate the various neurocognitive  functions and help them better understand their son’s status and  see the impact medication had on their son’s cognition. Vyvanse™ is a product of  Shire Pharmaceuticals.

CNS Vital Signs neurocognitive tests are psychometrically sound and include measures of the most common complaints of AD/HD:  inattention (Complex  Attention Domain),  impulsive responding (Complex Attention and Executive Function Domain), executive control (Executive Function, Cognitive  Function), and  speed of processing (Processing Speed Domain), and working memory (four‐part CPT). Clinicians can now easily and objectively measure  executive control, attention, and other important domains as part of their evaluation and management activities. CNS Vital Signs helps contribute to an  efficient, systematic continuity between evaluation and treatment (medication management). 

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Why Use CNS Vital Signs to Assess AD/HD? Frontal Lobe Objective Measure of Clinical Pathology Frontal Lobe Tests Symbol  Digit  Coding (SDC)

The CNS Vital Signs tests can compliment other “Executive Function”  assessments e.g., Brown AD/HD, BRIEF,  CONNERS, Barkley, etc. to help  identify and effectively address neurocognitive challenges that can have  dramatic impact on academic and vocational performance.

Neurocognitive Function ■ ■ ■ ■

Information Processing Speed Complex Attention  Visual‐Perceptual Speed Information Processing Speed

■ ■ ■ ■ ■

Executive Function Simple and Complex Reaction Time  Speed‐Accuracy Trade‐Off  Information Processing Speed  Inhibition / Disinhibition

Approx. 2.5 Minutes

■ ■ ■ ■

Executive Function: Shifting Sets Reaction Time Information Processing Speed Speed‐Accuracy Trade‐off

Continuous  Performance (CPT)

■ ■ ■

Sustained Attention Choice Reaction Time Impulsivity

■ ■

Sustained Attention Working Memory

Clinical Domains

Processing  Speed 

Measure: How well a subject recognizes and processes information i.e., perceiving,  attending/responding to incoming information, motor speed, fine motor  coordination, and visual‐perceptual ability. Relevance: Ability to recognize and  respond/react  i.e., fitness‐to‐drive, occupation issues, possible danger/risk signs or  issues with accuracy and detail. 

Executive  Function

Measure: How well a subject recognizes rules, categories, and manages or navigates  rapid decision making. Relevance: Ability to sequence tasks and manage multiple  tasks simultaneously as well as tracking and responding to a set of instructions.

Complex  Attention

Measure: Ability to track and respond to information over lengthy periods of time  and/or perform  mental tasks requiring vigilance quickly and accurately. Relevance: Self‐regulation and behavioral control.

Cognitive  Flexibility

Measure: How well subject is able to adapt to rapidly changing and increasingly  complex set of directions and/or to manipulate the information. Relevance: Reasoning, switching tasks, decision‐making, impulse control, strategy formation,  attending to conversation. 

Stroop  Test (ST) Approx. 4 ‐ 5 Minutes

Shifting  Attention (SAT)

Approx. 5 Minutes

4‐Part Continuous  Performance (FPCPT) Approx. 7 Minutes

Auto‐scored

Approx. 4 Minutes

Working  Memory Sustained  Attention

Measure: How well a subject can perceive and attend to symbols using short‐term  memory processes (4PCPT). Relevance: Ability to carry out short‐term memory tasks  that support decision making, problem solving, planning, and execution.   Enables  “right‐now” responses. Measure: How well a subject can direct and focus cognitive activity on specific  stimuli. Relevance: How well a subject can focus and complete task or activity,  sequence action, and focus during complex thought.

CNS Vital Signs is used throughout the world as a clinical tool to evaluate and manage ADHD. Executive Functioning, sometimes called executive control  system, is generally considered a frontal lobe (see orange section of the brain) neurocognitive system that controls and manages other cognitive  processes. It is considered a higher‐order brain function, which include attention, behavioral planning and response inhibition, and the manipulation of  information in problem‐solving tasks. Sometimes referred to as the "command and control" or the "conductor" of many cognitive skills. Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Neurobehavioral Feedback

Age: 34

Pre November 9, 2010

Post November 24, 2010

Many clinicians that provide  Neurobehavioral Feedback training  also use CNS Vital Signs assessment  Platform as part of their evaluation  and then to assess neurobehavioral  feedback treatment efficacy.  Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

Post March 7, 2011

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Brief Clinical Procedure Case Study Examples AD/HD    

Adolescent Assessment and Medication Management College Student Assessment and Medication Management AD/HD Evaluation and Cogmed Evidence‐Based Outcomes Neurobehavioral Feedback Longitudinal Tracking

TBI & PTSD   

27 year old Marine… 2 IED’s in Iraq… TBI & PTSD Posit Science Brain Fitness (24 yo professional baseball player) Cognitive Resilience Training

SLEEP 

Sleep Disorder Patient

OTHER   

Cognitive Fatigue; Sorting Out Comorbidities; Folic Acid, Plus Stimulant Measure Aerobic Exercise  Use in MCI Dementia

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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27 YO Marine… 2 IED’s: Neurocognitive Tests Robert, a 27 year old Marine  that was involved in 2  improvised explosive devices in  Iraq was struggling and was  referred to an experimental  treatment program using HBOT  (hyperbaric oxygen). Robert was  given CNS VS neurocognitive  tests and 3 health rating scales  (Medical Outcomes Survey SF‐ 36, Epworth Sleep Scale, & NPQ‐ 45) at baseline prior to  treatment. The baseline revealed frontal  lobe impairment and multiple  symptom deficits e.g. sleep,  depression, etc. 

Baseline Post-Injury 1.05.2009

Post-Injury Treatment 2.11.2009

Robert was reevaluated  following HBOT therapy,  Cognitive behavioral theory was  added due to Roberts current  emotional state. Post baseline  assessments were given one  month following the treatment. General improvement was seen  in both his cognitive and  symptom scores.

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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27 YO Marine… 2 IED’s: SF-36 1

2

Baseline Post-Injury Robert, a 27 year old  Marine was still  running 5 miles a day  and reported a high  pain tolerance. His scores for Role  Functioning , Energy/  Fatigue, Emotional  Well Being, Social  Functioning, and  Health Change was  confirmed  by a  spouses informant  scale and through  clinical interview. 

1 2

1 2

Post-Injury Treatment

Robert was drinking a  fifth of alcohol a week.

3

General improvement  was seen in his  symptom scores  following treatment.

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

3

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27 YO Marine… 2 IED’s: Epworth Sleep Baseline Post-Injury

Post-Injury Treatment

The patient is getting enough sleep if they score 6 or less. Scores of 7 or 8 are average. If the  patients score is 9 or more they should seek the advice of a sleep specialist without delay.

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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27 YO Marine… 2 IED’s: NPQ-45 Baseline Post-Injury

Post-Injury Treatment

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Posit Science: 24 Year Old Baseball Player

Pre Tom, a 24 year old professional  baseball player was hit in the  head with a baseball and was  struggling. He was referred to a  clinical practice in Florida  for  cognitive training using the Posit  Science System. Tom, was given  the CNS VS neurocognitive tests at baseline prior to treatment. The baseline revealed reaction  time impairment.

Post

Tom was reevaluated following  therapy. Post baseline  assessments were given one  month following the treatment.

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Cognitive Resilience Training

20 Year old soldier post IED

6 Week Cognitive Resilience program  Pre BASELINE Week One: Effective  Movement Training  including VIPR, TRX and  functional movement  assessment and remedial  interventions including  triangulated movement Week Two: Nutrition and  Hydration incorporating  Post 6 WEEK TREATMENT 10g fish oil daily, 300ml  water per 10kg, no  processed food, sugar,  alcohol etc. Week Three: Recovery  training using Heart Rate  Variability training and  mindfulness Mindset: Week Four, incorporating gratitude rituals, positive psychology based interventions, cognitive restructuring, HRV training, Mindfulness  training Mindset: Week Five, re‐socializing including Interpersonal Psychotherapy, Relaxation training, self‐hypnosis, visualization, calibrated exposure  desensitization therapy Week Six, Stress management, Heart Rate Variability training, review of nutrition and exercise rituals, advanced exposure to threatening stimuli A six week integrated solution based on exercise, nutrition/hydration, recovery and mindset interventions resulted in normalization of all parameters  measured and a return to active duties. Follow up treatment with medication in the field made little difference to deployment status. See www.roysugarman.com Integrated body‐brain solutions appear to be effective interventions for such clients

Enquiries: Dr Roy Sugarman USA: 480‐463‐1109 Aus: 0403 289 092

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Brief Clinical Procedure Case Study Examples AD/HD    

Adolescent Assessment and Medication Management College Student Assessment and Medication Management AD/HD Evaluation and Cogmed Evidence‐Based Outcomes Neurobehavioral Feedback Longitudinal Tracking

TBI & PTSD   

27 year old Marine… 2 IED’s in Iraq… TBI & PTSD Posit Science Brain Fitness (24 yo professional baseball player) Cognitive Resilience Training

SLEEP 

Sleep Disorder Patient

OTHER   

Cognitive Fatigue; Sorting Out Comorbidities; Folic Acid, Plus Stimulant Measure Aerobic Exercise  Use in MCI Dementia

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Sleep Case Study 1 PRE: Part of Sleep Assessment Protocol Dan a 39 Year Old Office Worker: Epworth Sleepiness Scale In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situation? 1

Sitting and reading

3 - High chance of dozing

2

Watching TV

2 - Moderate chance of dozing

3

Sitting inactive in a public place (e.g., a theater or a meeting)

2 - Moderate chance of dozing

4

As a passenger in a car for an hour without a break

1 - Slight chance of dozing

5

Lying down to rest in the afternoon when circumstances permit

2 - Moderate chance of dozing

6

Sitting and talking to someone

0 - Would never doze

7

Sitting quietly after a lunch without alcohol

0 - Would never doze

8

In a car, while stopped for a few minutes in traffic

0 - Would never doze

Epworth Score

10

The patient is getting enough sleep if they score 6 or less. Scores of 7 or 8 are average. If the patients score is 9 or more they should seek the advice of a sleep specialist without delay

NeuroPsych Questionnaire (NPQ) SF-45 Domain

Score

Severity

Attention Impulsive Memory Anxiety Panic Depression Mood Stability Aggression Fatigue Sleep Suicide

190 217 200 220 120 182 188 120 233 300 40

Moderate Moderate Moderate Moderate Mild Moderate Moderate Mild Severe Severe Not a Problem

Pain

120

Mild

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

Description The Neuropsych Questionnaire Short Form asks patients (or an appropriate observer) a series of questions about their clinical state. The questions are about the symptoms of various neuropsychiatric disorders. The terminology is similar to that used in the diagnostic manuals, and in many familiar clinical questionnaires and rating scales; but it has been simplified, and all symptoms are scored on the same metric. Scores are reported on a scale of 0 (not a problem) to 300 (severe). As a rule, scores above 225 indicate a severe problem; scores from 150-224 indicate a moderate problem; and scores from 75-149, a mild problem. A high score on the Neuropsych Questionnaire Short Form means that the patient is reporting more symptoms of greater intensity. It doesn't necessarily mean that the patient has a particular condition; just that he or she (or their spouse, parent or caregiver) are saying that they have a lot of intense symptoms. Conversely, a low score simply means that the patient (or caregiver) is not reporting symptoms associated with a particular condition, at least during the period of time specified. It does not mean that the patient does not have the condition. Just as some people over-state their problems, others tend to under-state their problems. The Neuropsych Questionnaire Short Form is not a diagnostic instrument. The results it generates are only meant to be interpreted by an experienced clinician in the course of a clinical examination.

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Every patient with SLEEP can have a Unique PROFILE. 1

Pre CPAP: May 12, 2011

2

Post CPAP: June 24, 2011

Baseline Prior to Sleep Study

Dan, a thirty‐nine year old man  struggling vocationally was  given CNS Vital Signs VSX  BRIEF‐CORE Clinical Battery…  he scored low in 6 of 9  cognitive domains (pre‐cpap).  After examining the H&P, the  test results, and the SF‐36,  NPQ‐45, and Epworth Sleep  rating scales; Dan underwent a  sleep study and was prescribed  CPAP. Following four weeks of  compliant CPAP therapy he  was administered the CNS Vital  Signs test again (post‐cpap). The CNS Vital Signs  report is  available seconds after the  testing session ends and is a  useful tool fort measuring   treatment effect and helping  clinicians reinforce CPAP  compliance to maximize  neurocognitive effect. 

“I was like “WOW what a difference” when I was able to see the benefits of the CPAP machine…” Sleep Study Participant

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

Retest Following Four Weeks of Compliant CPAP

“It was like getting my old husband back… he wanted to quit the CPAP machine… I said let’s give it 3 weeks more… now I think he is motivated.” Sleep Study Participant Spouse

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Brief Clinical Procedure Case Study Examples AD/HD    

Adolescent Assessment and Medication Management College Student Assessment and Medication Management AD/HD Evaluation and Cogmed Evidence‐Based Outcomes Neurobehavioral Feedback Longitudinal Tracking

TBI & PTSD   

27 year old Marine… 2 IED’s in Iraq… TBI & PTSD Posit Science Brain Fitness (24 yo professional baseball player) Cognitive Resilience Training

SLEEP 

Sleep Disorder Patient

OTHER   

Cognitive Fatigue; Sorting Out Comorbidities; Folic Acid, Plus Stimulant Measure Aerobic Exercise  Use in MCI Dementia

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Case Study: Cognitive Fatigue – ADD 1 Baseline / Patient In-take Lisa, a 54 year old mother of 2 would  be driving in Dallas traffic and start  having “Mini‐Seizures” that would  require her to pull to the side of the  road and her husband would need to  leave work to rescue her. Lisa had been to numerous doctors  and generally prescribed multiple anti‐ depressants and anti‐anxiety  medications with little or no effect. Lisa was referred to a Neurologist and  was tested using CNS VS, on the last  test she started exhibiting the  symptoms seen while driving.

2 Post Folic Acid Therapy…

Lisa was given a number of blood and  genetic tests  and a was reevaluated  following therapy. Post baseline  assessment was given one year later  post folic acid therapy. Lisa had not  experienced any “Mini‐Seizures” one  year later and improved cognition was  reveled using CNS VS retest. Based on  the follow‐up exam and past history  Lisa was administered the Adult  AD/HD scale and based on the follow‐ up test, history, and rating scale she  was prescribed a low dose of  Vyvanse… 

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

then assessed for Attention Deficit

Administered Adult AD/HD Scale 22

2

Lisa’s Adult AD/HD Rating Scale

1

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

3 ‐ Often

2

How often do you have difficulty getting things in order when you have to do a task that requires organization?

4 ‐ Very Often

3

How often do you have problems remembering appointments or obligations?

2 ‐ Sometimes

4

When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

4 ‐ Very Often

5

How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

2 ‐ Sometimes

6

How often do you feel overly active and compelled to do things, like you were driven by a motor?

2 ‐ Sometimes

7

How often do you make careless mistakes when you have to work on a boring or difficult project?

3 ‐ Often

8

How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

3 ‐ Often

9

How often do you have difficulty concentrating on what people say to you, even when they are speaking to you  directly?

4 ‐ Very Often

Part A (Inattentive)

10

How often do you misplace or have difficulty finding things at home or work?

11

How often are you distracted by activity or noise around you?

12

How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

13

How often do you feel restless or fidgety?

14

How often do you have difficulty unwinding and relaxing when you have time to yourself?

27 3 ‐ Often 2 ‐ Sometimes 1 ‐ Rarely 2 ‐ Sometimes 2 ‐ Sometimes

15

How often do you find yourself talking too much when you are in social situations?

1 ‐ Rarely

16

When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking  to, before they can finish them themselves?

1 ‐ Rarely

17

How often do you have difficulty waiting your turn in situations when turn taking is required?

18

How often do you interrupt others when they are busy?

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

1 ‐ Rarely 2 ‐ Sometimes Part B (Hyperactive/Impulsive) 15 ASRS Total Score 42

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3

Lisa’s Cognitive Fatigue – ADD Case Study, continued

A month and a half later Lisa was  retested and the effect of a low  dose stimulant, adjusted diet and  exercise was revealed both  objectively by the CNS Vital Signs  test as well as by statements from  Lisa. COMMENT: One of the most difficult  assessments is determining the  comorbidity of cognition  dysfunction that leads to depression  or is the depression caused from  metabolic or environmental  circumstances. The following two pages has  information from a recent study  that can help demonstrate how CNS  Vital Signs can help clinicians sort  out possible underlying conditions  that may need to be ruled in or out.

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Helping Assess Comorbidities Cognition and Depression “Indeed, there is some suggestion that cognitive or  executive functioning deficits may be a trait risk factor  for depression (Douglas and Porter, 2009; Frasch et al.,  2009; Micco et al., 2009; Reppermund et al., 2009).  Furthermore, worse neuropsychological test  performance at baseline is associated with poorer  response to treatment (Dunkin et al., 2000; Kampf‐ Sherf et al., 2004; Mohlman and Gorman, 2005), and  cognitive deficits are more pronounced in patients  who are unemployed (Baune et al., 2010). It is possible  that treatment refractory depression is a subtype  characterized in part by cognitive impairment. The accurate identification and quantification of neurocognitive impairment are important for research relating to  neurobiological underpinnings, treatment, and functional outcome in patients with mood disorders. It is essential,  methodologically, that we have accurate methods for identifying those patients who are objectively cognitively impaired and  separate them from patients who have the subjective experience of poor thinking skills or thinking that is easily perturbed by  negative affect, but perform normally on cognitive testing in controlled conditions. The treatments and outcomes for these two  groups may differ markedly, as well as the prognosis.” Source:  Identifying a cognitive impairment subgroup in  adults with mood disorders. J Affect Disord. 2011  Aug;132(3):360‐7. Epub 2011 Mar 25. http://www.ncbi.nlm.nih.gov/pubmed/21439647

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Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Cognition and Depression Cognitive Flexibility

Healthy Control Mood Disorder, Normal Cognition Mood Disorder, Cognitive Impairment

Domain scored from two venerable AD/HD tests

45 40 35 30 25 20 15 10 5 0 40-49

50-59

60-69

70-79

80-89 90-99 100-109 110-119 120-129 130-139

Fig. 3. Distributions of CNS Vital Signs cognitive flexibility index score in patients with or without  impaired cognition. Figure note: Healthy control, N=660. Mood disorder, normal cognition, n=128.  Mood disorder, cognitive impairment, n=58. *Normative scores were truncated at 40. Each value  represents the percentage of subjects in that score range.

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Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Human Performance Application Source:  J Clin Psychol Med Settings (2009) 16:186–193; Steven Masley, Richard Roetzheim, Thomas Gualtieri

Aerobic Exercise Enhances Cognitive Flexibility Introduction: Physical activity is believed to prevent cognitive decline and  may enhance frontal lobe activity… The association between physical fitness  and cognitive health is as intuitive as ‘‘mens sana in corpore sano.’’ Over time,  this Latin phrase has come to mean that only a healthy body can produce or  sustain a healthy mind…  Conclusion: Over a 10 week period, increasing frequency of aerobic  activity was shown to be associated with enhanced cognitive performance, in  particular cognitive flexibility, a measure of executive function.

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Human Performance Application Percent Increase in Cognitive Flexibility with Increasing Frequency of Aerobic Exercise

Percent Increase 

35% 30% 25% 20% 15% 10% 5% 0%

Control, Minimal Exercise

Moderately Frequent Exercise

Highly Frequent Exercise

Source:  J Clin Psychol Med Settings (2009) 16:186–193; Steven Masley, Richard Roetzheim, Thomas Gualtieri

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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HOW? Neurocognitive Health Management Aggressive Evaluation, Management and Monitoring of MCI/Dementia Syndromes Don Schmechel et,al. ICAD Paris 2011

First Visit

Second Visit 4-6 Weeks

2 Month Visit

3 Month Depending on Intervention

History & Physical ………………………………………………………………..… Neurocognitive Exam ………………………………………………….………… MMSE Screen ………………………………………………………………………… Social Work Consultation & Overview ………………………………………….. Review/Order Neuroimaging, Sleep Studies, etc. …………………………….. Blood Work …………………………………………………………………………… Genetic Testing ………………………………………………………………………. Other Blood Work (homocysteine, inflammatory indices, etc.) …………………………..… Establish Primary, Secondary, Medical Diagnosis …………………………… Computerized Neurocognitive Testing (CNS Vital Signs) ……………………………………………… Review of Clinical Status ……………………………………………………………………………………………… Review of Genetics, Blood Work, Imaging ……………………………………………………………… Revision of Diagnosis ………………………………………………………………………………………. Selection of Interventions (Nx-Nutrition, Rx-Pharmacologic, Ex-Exercise, etc.) ……………………………………………….. Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Why CNS Vital Signs? CNS Vital Signs valid, reliable, and affordable  ‘research quality’ NEUROCOGNITIVE  & BEHAVIORAL  HEALTH assessment platform can be easily  configured and deployed depending on each  practices or researchers needs and goals. The CNS  Vital Signs assessment platforms helps to support a  practices comprehensive, state‐of‐the‐art clinical  assessment, and evidence‐based treatment services  for children, adolescents, and adults across the  lifespan by: 



 

Accurately measuring and characterizing a  patient’s neurocognitive function based on his  or her status or effort Facilitating the thinking about the patient’s  condition (50+ well known medical and health  rating scales)and helping to explain the  patient’s current difficulties Optimizing serial administration which helps to  monitor and guide effective intervention. Systematically collecting brain function,  behavioral, symptom, and comorbidity data  enabling outcomes and evidence‐based  medicine

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

Enhanced Brain & Behavior Evaluation and Care Management OBJECTIVE, PRECISE, and STANDARDIZED… Customizable  Toolboxes or Test Panels Supporting many Neurological,  Psychiatric, & Psychological Clinical Guidelines

$ Extend Practice Efficiency Objective and Evidence‐Based  Assessments, Auto‐Scored and  Systematically Documented. (HIPAA Enabled)

Enhanced Revenue Streams Expanded Services with  Well Established Billing  Codes to Improve Practice  Performance

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CNS Vital Signs Vision:

Advancing Neurocognitive Assessment Across the Lifespan Acquisition

Development

Disposition + or ‐ Learning Abilities Early Development Genetics

Decline

Organizing, Managing, and Controlling Behaviors and Activities

Expectations

Training & Coping

Maternal Health

Maintenance

Cognitive, Emotional, Physical, and Social Challenges

Sense of Control

Learning Responses

Self‐Confidence

Self‐Controlled

Peer Influence

Response to Stress

Parental Care

Physical and Mental Health and Wellbeing S l e e p   E x e r c i s e  N u t r i t i o n............ S l e e p   E x e r c i s e  N u t r i t i o n............ S l e e p   E x e r c i s e  N u t r i t i o n

Learning, Training, Experiencing and Events S c h o o l Pre ‐ S c h o o l

W o r k

R e t i r e m e n t

Environment(s) F a m i l y   C o m m u n i t y   L i f e s t y l e...  F a m i l y   C o m m u n i t y   L i f e s t y l e.... F a m i l y   C o m m u n i t y   L i f e s t y l e HEALTH KNOWLEDGE, HEALTHY HABITS, & ACCESS TO CARE Prenatal Early‐Childhood (0‐4)

Child (5‐12)

Adolescent

Lifestage

Adults

Older Adults

Adapted From:  Mental Capital and Wellbeing: Making the most of ourselves in the 21st century

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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Advancing Neuro-Psychiatric Care… Assessing Neurocognition is a Key Factor Accruing Mental Capital Neurocognitive skills are cumulative;  success builds upon success. Thus early abilities ‐ or their lack ‐ contribute heavily to future success  or failure. Early capability makes later learning  more efficient and increases the  complexity of what can be learned

Attitudes Aspirations Beliefs Values Talents

Knowledge Beliefs &  Skills

Family Education  Level &  Involvement Home and Family Environment

Academic Vocational Training &  Abilities School – Work Environment

Learning Environments

Mental Wellbing Outcomes

Mental Wellbeing CORE

SelfConcept

Symbolic Skills

Self-Efficacy Self-Esteem

Positive

Performance

Social Skills

Trajectory

Executive Control Auditory Processing Visual Processing Visuo-Spatial Motor Systems

Sensory

Self Monitoring Self – Reflection Self - Control

Neurocognition

Language Dyscalculia Dyslexia AD/HD Hearing/Deafness Autism Asperger's Depression Anxiety

Attention Reaction Time Processing Speed Reasoning Psychomotor Speed Memory Executive Function Cognitive Flexibility

Intellectual Functioning Cognitive Flexibility Resilience Optimism Coping style Self-esteem Self-efficacy Social engagement Social inclusion Employability

Social Perception Social Knowledge Communication Skills

+

Motivation Problem Solving Learning Social

Social Cognition Motivation Autonomy Mastery Purpose

-

Delinquency School Failure Depression Mental Ill-health Criminality Substance Abuse Teen Pregnancy Eating Disorders

Negative

Performance Trajectory

Emotion

Gene – Environment Interaction Prenatal Early ‐ Childhood (0‐4)

Genetic and Maternal Health Disposition

Child (5‐12)

Adolescent

Adults

Older  Adults

Lifestage Adapted From:  Mental Capital and Wellbeing: Making the most of ourselves in the 21st century

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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NEXT STEPS:

Contact Us…

Getting Started

Learn More

Step One: Register at www.CNSVS.com After registering download the VSX  ‘Brief‐Core”  Assessment Software with 5 FREE Test Sessions…  Take it for a test drive.

Contact me to receive report examples, case  studies, administration guides etc.

Step Two: Schedule a FREE One‐on‐One In‐ Service Webinar… Contact CNS Vital Signs   Support [email protected] with dates and  times that you will be available. After the webinar the total CNS Vital Signs  Assessment platform (Web & Local) can be  configured to meet your practice needs.



Website: www.CNSVS.com



Phone: 888.750.6941



Email: [email protected]



Address: – 598 Airport Blvd. – Suite 1400 – Morrisville, NC 27560

“The webinar training was terrific… it covered the Validity & Reliability of the platform, the  interpretation of results, billing and coding,  testing protocol, and the integration of the CNS  Vital Signs platform into our practice.”   Practice Administrator

Solutions for Measuring , Monitoring, and  Managing Neurocognitive and Behavioral Health

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